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4/25/2017
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Partnership for the Prevention and Early Detection of Lung Cancer
MPRO’s Michigan Cancer Control Initiative &
Hills & Dales General Hospital’s Lung Cancer Screening Program
Low dose CT (LDCT) Lung Cancer Screening
Peggy Davidson, ARRT (CT) (R) (M), RDMS (ABD) (BR) RDCS
Director of Radiology
Trisha Meinhard, BBSManager of Physician Practices
Hills and Dales General HospitalRadiology Department
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National Lung Screening Trial (NLST), 2002-2010
• Low-dose helical computed tomography (LDCT) vs. standard chest X-ray
• 53,454 former or current heavy smokers: ages 55-74
• Participants randomly assigned to 3 annual screens with either LDCT or X-ray
• Participants who received LDCT scans had a 15-20% lower risk of dying from lung cancer than participants who received standard chest X-rays
• Adenocarcinomas and squamous cell carcinomas detected more frequently at the earliest stage by LDCT compare to chest X-ray
Results
As a result of NLST evidence, lung cancer screening with LDCT has been designated as a Grade B recommendation by USPSTF
Grade B = USPSTF recommends this service, there is moderate certainty that the benefit of this service is moderate to substantial
U.S. Preventive Services Task Force Recommendation
Lung Cancer: ScreeningSummary of Recommendation and Evidence
Population Recommendation Grade
Adults Aged 55-80, with a History of Smoking
The USPSTF recommends annual screening for lung cancer with LDCT in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery
BRelease Date: December 2013
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Facility Information
• Cat Scan department accredited by the American College of Radiology
• Designated Lung Cancer Screening Facility by the American College of Radiology
What is a LDCT Lung Screening?
A low dose lung cancer screening is a non-contrast
Cat Scan exam that is performed on patients who
are at risk of developing lung cancer
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Program Preparation
1. Reviewed all CMS guidelines for LDCT
2. Joined NRDR (National Radiology Data Registry)
3. Prepared patient history sheet
4. Developed documentation process for information to be
entered into the NRDR
5. Set up ordering and scheduling process
6. Set up steering committee
• Selected Cat Scan Technologist as a champion for performing and completing all documentation for LDCT screening exams
• Set up LDCT screening protocols according to standards set by the American College of Radiology
Program Preparation
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• Education packets for providers contain:o Procedure benefits and requirementso Billing requirementso Ordering requirementso Availability of smoking cessation programmingo Benefits of LDCT vs. chest X-ray
• Explanation of Lung Rad assessment and follow up process
Education for Providers
Counseling and Shared Decision-Making Visit
Before the first lung cancer LDCT screening occurs,
the patient must receive a written order for LDCT lung
cancer screening during a lung cancer screening
counseling and shared decision-making visit
Counseling and Shared Decision-Making visits must include the following elements and be appropriately documented in the patient’s medical record
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Elements of a Written Order for LDCT Lung Cancer Screening
1. Patient’s date of birth 2. Calculated pack-year smoking history (number)3. Current smoking status, and for former smokers,
the number of years since quitting smoking4. A statement that the patient is asymptomatic (no
signs or symptoms of lung cancer)5. The National Provider Identifier (NPI) of the
ordering practitioner
Elements of a Counseling and Shared Decision-Making Visit
• Conducted by a physician or qualified non-physician practitioner
• Determination of patients’ eligibility for screening as stated above
• “Shared decision-making” includes:o Use of one or more decision aids
o Benefits and harms of screening
o Follow-up diagnostic testing
o Over-diagnosis and treatment
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Elements of a Counseling and Shared Decision-Making Visit
• Counseling on importance of beginning or maintaining tobacco smoking abstinence
• Provide information about tobacco cessation interventions
• If appropriate, furnish a written order for lung cancer screening with LDCT
CPT Code – Counseling and Shared Decision-Making Visit
• CPT Code to bill – G0296
G0296 Definition:
Counseling visit to discuss need for lung cancer
screening using low dose CT scan. Service is for
eligibility determination and shared decision making.
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ICD-10 Diagnosis Code – Tobacco Use
• Counseling charge must be billed with ICD-10 diagnosis code Z87.891
Z87.891 Definition:
Personal history of tobacco use/
personal history of nicotine dependence.
Patient Criteria for LDCT Lung Screening
• To qualify for LDCT Lung Screening patients must meet the following criteria:o 55 to 77 years of ageo Be asymptomatic
• Meaning no signs or symptoms of lung cancer
o Have a tobacco smoking history of at least 30 pack-years
• 1 pack-year = 1 pack per day for 1 year• 1 pack = 20 cigarettes
o Be a current smoker or have quit within the last 15 years
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LDCT Orders by Paper or EHR
Patient name: ____________________________________________Birthdate:________________Ordering date: ___________________________Ordering Physician: ________________________Procedure Requested: Low Dose CT Chest Lung Cancer ScreeningReason for exam: Screening for Lung Cancer
Please complete the following patient history/assessment:Age is 55-77? Yes or NoCurrently smoking? Yes or NoTobacco smoking history of 30 pack-years or more? Yes or NoHas the patient been offered “Tobacco Cessation” counseling? Yes or No CT Chest within past year? Yes or NoAsymptomatic, no clinical signs or symptoms of lung cancer? Yes or NoPatient is oxygen dependent? Yes or NoDoes patient have a Pacemaker/Defibrillator? Yes or NoDoes the patient have metal implants in the spine? Yes or NoWhat is the patient current weight? _______________What is the patient’s current height? ______________
By signing this order, I am certifying that the patient participatedin the “Shared Decision –Making” visit and has received “Lung Cancer Screening” counseling? Yes or No
Physician Signature__________________________________________________
LDCT Costs and Codes
• Cost of LDCT scan - $235 plus the radiologist reading fee
• CPT code G0297
• If the patient needs to come back for a follow up exam: CPT 71250 (CT without contrast)
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Lung QuestionnaireName:__________________________________ MRN:___________ Phone:___________________Address:_____________________________________________________ S.S. #:___________________City:_____________________________ State:___________________ Zip:_____________________Age:_____ D.O.B.______________ Gender: M / F Race:___________________Prior Study: Y / N Weight:____________ Pregnant: Y / NCurrent Height:______ Tallest Height:______ Height Loss:______________
COPD: Y / N Emphysema: Y / N Pulmonary Fibrosis: Y / N Coronary Artery Disease: Y / NCongestive Heart Failure: Y / N PVD: Y / N Lung CA: Y / N Other CA: Y / N
Smoking Status:Smoker Former Smoker Never Smoker Smoker: Status Unknown UnknownNumber of packs per day:__________ Number of years since quit:_______________Smoking Cessation Provided: Y / N Documentation on Shared Decision Making: Y / NRadon Exposure: Y / N Tobacco Use: Y / N Alcohol Use: Y / N
Physical Activity:None Occasional Frequent
Level of Education:8th grade or less High School Certificate PGM Associates Bachelors Unknown
Occupational Exposure:Silica Cadmium Asbestos Arsenic Beryllium Chromium Diesel Fumes Nickel
History of Cancers:Prior Lung CA Lymphoma Head and Neck Bladder Other_____________________
Family History:Lung CA in 1st degree relative Family HX of Lung CA 2nd Hand Smoke ExposureSurgical History:________________________________________________________________________
Lung-RADS Version 1.0 Assessment CategoriesRelease date: April 28, 2014
American College of Radiology (ACR) Lung Assessment Categories (0-3)
CategoryCategory
DescriptorCategory Findings Management
Probability of
Malignancy
Estimated Population Prevalence
Incomplete - 0Prior chest CT examination(s) being located for comparison Additional lung cancer screening CT
images and/or comparison to prior chest CT examinations is needed
n/a 1%Part or all of lungs cannot be evaluated
NegativeNo nodules and definitely benign
nodules1
No lung nodules
Continue annual screening with LDCT in 12 months
<1% 90%
Nodule(s) with specific calcifications: complete, central, popcorn, concentric rings and fat containing nodules
Benign Appearance or Behavior
Nodules with a very low likelihood of
becoming a clinically active cancer due to size or lack of growth
2
Solid nodule(s):< 6 mmnew < 4 mm
Part solid nodule(s):< 6 mm total diameter or baseline screening
Non solid nodule(s) (GGN):< 20 mm OR≥ 20 mm and unchanged or slowly growing
Category 3 or 4 nodules unchanged for ≥ 3 months
Probably Benign
Probably benign finding(s) – short
term follow up suggested; includes nodules with a low
likelihood of becoming a clinically
active cancer
3
Solid nodule(s):≥ 6 to < 8 mm at baseline OR New 4 mm to < 6 mm
6 month LDCT 1-2% 5%Part solid nodule(s)
≥ 6 mm total diameter with solid component < 6 mm ORNew < 6 mm total diameter
Non solid nodule(s) (GGN) ≥ 20 mm on baseline CT or new
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Lung-RADS Version 1.0 Assessment CategoriesRelease date: April 28, 2014
CategoryCategory
DescriptorCategory Findings Management
Probability of
Malignancy
Estimated Population Prevalence
Suspicious
Findings for which additional testing
and/or tissue sampling is
recommended
4A
Solid nodule(s):≥ 8 to < 15 mm at baseline ORGrowing < 8 mm ORNew 8 to < 8 mm 3 month LDCT; PET/CT may be
used when there is a ≥ 8 mm solid component
5-15% 2%Part solid nodule(s):≥ 6 mm with solid component ≥ 6 mm to <8 mm ORWith a new or growing < 4 mm solid component
Endobronchial nodule
4B
Solid nodule(s):≥ 15 mm ORNew or growing, and ≥ 8 mm
Chest CT with or without contrast, PET/CT and/or tissue sampling depending on the *probability of malignancy and comorbidities.
PET/CT may be used when there is a ≥ 8 mm solid component
> 15% 2%Part solid nodule(s) with:A solid component ≥ 8 mm ORA new or growing ≥ 4 mm solid component
4XCategory 3 or 4 nodules with additional features or imaging findings that increases the suspicion of malignancy
Other
Clinically significantor potentially
clinically significant findings (not lung
cancer)
S Modifier – may add on to category 0-4 coding As appropriate to specific finding n/a 10%
Prior LungCancer
Modifier for patients with a prior diagnosis of lung cancer who return to screening
C Modifier – may add on to category 0-4 coding - - -
American College of Radiology (ACR) Lung Assessment Categories (0-3)
• Rounding with providers
• Rounding with all staff associated with program
• Bi-monthly LDCT steering committee meeting to review scheduling, billing, ordering, results, quality and follow-up
Follow Up
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A Note on Coverage
• Medicare coinsurance and Part B deductible are waived for this preventative service
• Medicare Patients will not have a financial responsibility for the counseling or lung cancer screening LDCT scan
Patient Population DemographicsDemographics Clinic A Clinic B
Unique Patients 4,051 1,733
Total Encounters 3,892 8,358
Male 38% 50%
Female 62% 50%
Medicare 16% 31%
Medicaid 18% 11%
Self-Pay 1% 1%
Private Payer 65% 56%
< 50 years old 64% 31%
> 50 years old 36% 69%
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LDCT Clinic RegistryAge Sex Pack Years Last CT Chest
Next Appt.
Notes
73 F 50 2/23/16 Had scan on 7/26/16
67 M 35 open order 4/11/17 If he doesn’t get regular CT done and receives cessation counseling, could get LDCT scan
62 F 30 12/15/2015 4/3/17 Pt. requested scan 6 months ago but was not eligible then. If she doesn’t have a regular CT chest and gets counseling for quitting she can have it
55 F 15.5
55 F 15
60 F 8.75 2/21/17
61 M 100 9/22/2016 3/2/17
61 F 11
70 M 63 3/22/17 Had LDCT 10/27/16
61 F 30 Had LDCT 1/24/17
74 M 50
57 F 14
57 F 45 3/14/17
62 M 45 7/11/17
65 F 20
66 M 40 Had LDCT 11/15/16
Program Growth
May 2016
Average of 3 to 4 patients
per month
Today
Average of 8 to 10 patients
per month
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Program Growth
• Lessons learned during program development
• <10 patients screened per month seems like a small number though, within the context of patient eligibility, is quite a few patients and growing
Forming a Partnership
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MPRO’s Michigan Cancer Control Initiative
Julee Campbell, MPHClinical Quality Consultant
Tesia Looper, MSASenior Clinical Quality Consultant
Who is MPRO?
Evidence based, data-driven quality
improvement insights
Thoughtful, impartial utilization review and dispute
resolution services
Innovative problem solving solutions and technical assistance
“HELPING HEALTHCARE GET BETTER”
QUALITYIMPROVEMENT
REVIEWSERVICES
CONSULTING SERVICES
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Project Partners
Initiative ObjectivesIncreasing Community Awareness
for Early Detection
Evidence-Based
Interventions
Personalized Technical
Assistance
Leveraging EHR and
Data
Provider and Community Education Michigan
Cancer Control
Initiative
Michigan Cancer Control
Initiative
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Initiative Components
Breast Cancer
Cervical Cancer
Colorectal Cancer
Lung Cancer
Smoking Cessation
Lung Cancer Screening (LDCT)
+10%
+10%
+5%
+5%
Percentage Increase Goals:
• 2nd most commonly diagnosed to prostate cancer in men and breast cancer in women
• 2016 estimates (US):o 224,390 new cases, 158,080 deaths (70.5%)
• 2016 estimates (Michigan):o 8,440 new cases, 6,030 deaths (71.5%)
• In 2012, less than 20% of lung cancer cases were diagnosed in the localized stage
Which type of cancer represents the leading cause of
cancer deaths for Michigan men and women?
Lung Cancer
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Health Disparities
• Lower SES households are more likely to be current smokers
• African American men have the highest rate of new cases and of death due to lung cancer
• Michigan has higher rates of smoking among adults compared to national average (23.3% vs. 19.6%)
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Implementing Evidence-Based Interventions | Sharing Best Practices
Technical Assistance
Patient Reminders
• Utilizing EHRo Targeted messaging through
patient portals
o Retrospective identification of eligible patients
• Updating current patient recall methodso Letters, emails, texting, widgit
Screen for Life, National Colorectal Cancer Action Campaign, CDC
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Provider Reminders
• Utilizing EHRo Updating and implementing
clinical decision support (CDS) and point-of-care alerts based on patient criteria
o Implementing and refining practice-wide screening protocols Clinical Protocol for the Early Detection of
Colorectal Cancer (CRC), March 2017,Michigan Cancer Consortium (MCC)
Resources & Small Media
• Updated screening recommendations
• Current news and legislationrelating to cancer screening
• Financial assistance resources
• Provider- and patient-facingtoolso Pack year calculator
(http://www.shouldiscreen.com/pack-year-calculator/)
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Educational Sessions
• Targeting providers for ongoing educationo Prevention & screening
o Best practices
o Strategies for implementation
o Financial assistance resources
• Session recordings availableo https://www.youtube.com/user/MPROQIO
Educational Session Schedule Michigan Cancer Control Initiative, MPRO
Resource Spotlight:
Patient Version Provider Version
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Provider Assessment & Feedback
• Benchmark screening data on multiple levels:o Provider
o Practice
o Health System
o All Participants
• Focus and individualize technical assistance
Partnership and Future Directions
Hills & Dales General Hospital and MPRO
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• Sharing best practices to engage more patients in the Hills & Dales Freedom From Smoking Programo Sessions for hospital employees
o Involving friends and family in session activities
o Future programming held in primary care offices
o Sharing educational and statistical resources
Smoking Cessation
Lung Cancer Screening
• Establishing eligible patient denominatorso Developing registry of patients meeting lung
cancer screening criteria
o Targeting reminders and screening education to these patients
o Recapturing patients for annual screening
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Lung Cancer Screening
• Provider education around mode of screeningo Promoting LDCT over traditional chest X-ray
o Screening decision tools and resources to guide shared decision making visit
o Providing guidance on how to refer patients to Hills & Dales Lung Cancer Screening Program
Questions?
Julee Campbell, MPHClinical Quality Consultant
Tesia Looper, MSASenior Clinical Quality Consultant
Peggy Davidson, ARRT (CT) (R) (M), RDMS (ABD) (BR) RDCS
Director of [email protected]
Trisha Meinhard, BBSManager of Physician [email protected]
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References1. LungRADS Assessment Categories. American College of Radiology. https://www.acr.org/Quality-Safety/Resources/LungRADS
2. Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening. The New England Journal of Medicine. http://www.nejm.org/doi/full/10.1056/NEJMoa1102873#t=article
3. Lung Cancer: Screening. U.S. Preventive Services Task Force. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung-cancer-screening
4. Lung Cancer in Michigan. MDHHS. http://www.michigan.gov/documents/mdch/LungCaFactSheet_497920_7.pdf
5. Michigan Cancer Consortium Tool of the Month. November is National Lung Cancer Awareness Month. http://www.michigancancer.org/PDFs/ToolOfTheMonth/November2016.pdf
6. State Cancer Profiles. CDC. https://statecancerprofiles.cancer.gov/map/map.withimage.php?26&001&047&00&0&01&0&1&5&0#results
7. Age-Adjusted Invasive Cancer Incidence Rates in Michigan. Michigan Cancer Surveillance Program. http://www.cancer-rates.info/mi/
8. Cancer Statistics Center. American Cancer Society. https://cancerstatisticscenter.cancer.org/?_ga=1.55783851.1299241662.1479700022#/state/Michigan
9. Screen for Life: National Colorectal Cancer Action Campaign. https://www.cdc.gov/cancer/colorectal/sfl/index.htm
10. Clinical Protocol for the Early Detection of Colorectal Cancer (CRC), March 2017. http://www.michigancancer.org/colorectal/PDFs/Guidelines/CRCClinicalProtocol.pdf
11. Michigan Tobacco Quitline. https://michigan.quitlogix.org/
12. The Great American Smokeout. American Cancer Society. https://www.cancer.org/healthy/stay-away-from-tobacco/great-american-smokeout.html
13. Lung Cancer CT Screening: Should I get screened? University of Michigan. http://www.shouldiscreen.com/
14. About Lung Cancer: Pack year calculator. University of Michigan. http://www.shouldiscreen.com/pack-year-calculator/
15. Michigan Cancer Control Initiative Webinar Schedule. MPRO. http://media.wix.com/ugd/50392a_000ca8eb677d4880ae349db4bb21d960.pdf
16. Lung Cancer Screening Decision Tools: Patient and Provider versions. MPRO. http://www.mpro.org/lung-cancer
